Part I. CARE PLAN TEMPLATE
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Data Supportive data for diagnosis (only data related to the nursing diagnosis you have chosen) |
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Nursing Diagnosis |
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Outcomes (measurable, with due date appropriate to term) Short-term Intermediate-term Long-term |
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Nursing Interventions (Be specific). Minimum 3 interventions. One MUST be a teaching intervention with 3 resources for the resident/ family to learn from |
Give rationale for each nursing action. Why or how will each nursing action help to relieve the problem? Cite the reference, author and page number, for each rationale. |
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1. 2. 3. |
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2. 3. |
©2019 Keith Rischer/www.KeithRN.com
Assessment & Reasoning
Respiratory System
Suggested Answer Guidelines
John Franklin, 35 years old
Suggested Respiratory Nursing Assessment Skills to Be Demonstrated:
• Inspection: Client positioning – tripod, position of comfort; (face) nasal flaring,
pursed lips, color of face, lips;
(posterior)level of scapula – rise evenly, use of accessory muscles
anterior/posterior, sternal/intercostal
retractions. Quality and pattern of
respirations.
• Palpation: (posterior) down the back sequentially checking for tenderness/pain, warmth, crepitus & fremitus
(best with ball of hand), chest wall expansion(symmetry) – thumbs over
spine and fingers spread like butterfly
wings-pneumonia, pneumothorax. Assess for masses, bulges, muscle tone
• Percussion: Across and down back for resonance vs hyperresonance (pneumothorax), dullness (pneumonia).
Avoid percussing over bone.
• Auscultation: Posterior – down the back sequentially from C7 (lung apex) to T10; anterior – above clavicles to
sixth rib (xiphoid); flanks from axillae to 8th rib. Ladder type sequence moving right to left for comparison.
Listen for full inspirations and expiration.
• Palpation, percussion and auscultation follow same pattern and avoids scapula
and spine (posterior) and
mammary tissue (anteriorly) – assess as close to chest wall as possible. Compare left to
right for aeration =
Make Learning Active!
• Role play or go through the interview/body assessment process – student to student or as a group.
• Review the case study as an application exercise in small groups or together as a class.
• Depending on your program some of this content in the case study may not have been taught. Do not let
that prevent you from utilizing this case study! Instead use it to promote learning by having students
identify what they do not yet know and provide guidance to where they can find the information in the
textbook or on the internet to address knowledge gaps. This is educational best practice and another way
to scaffold knowledge!
© 2019 Keith Rischer/www.KeithRN.com
Present Problem:
John Franklin is a 35-year-old African American male who has a history of hypertension and asthma who smokes ½ ppd
since the age of eighteen. He began to feel more short of breath after supper today and began to have a persistent non-
productive cough. He ran out of his albuterol inhaler two months ago and has audible expiratory wheezing when he
comes to the triage window of the emergency
department (ED).
John is promptly brought to a room in the ED and you are the nurse responsible for his care.
What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
History of asthma who smokes ½ ppd since
the age of eighteen.
He began to feel more short of breath after
supper and began to have a persistent non-
productive cough.
He ran out of his albuterol inhaler two
months ago
Audible expiratory wheezing when he comes
to the triage window of the emergency
department (ED).
Having a history of asthma with his clinical presentation confirms that
the most likely explanation for his respiratory distress is an asthmatic
exacerbation. Knowing that he is a smoker also increases his likelihood
to have an exacerbation due to the irritants that smoking contributes.
Having a nonproductive cough is consistent with an asthmatic
exacerbation or allergic reaction. If his cough was productive and had
color to it such as yellow or green that would be more suspicious for an
infectious problem such as bronchitis or pneumonia.
Knowing that he has no way to treat his exacerbation contributes to the
severity of his symptoms. As a nurse, one of our main roles is to educate
our patients. The nurse should revisit this once the patient is stabilized
When adventitious breath sounds such as wheezing are audible without
even requiring a stethoscope this is a clinical red flag and is
present
because of the severity of his symptoms and exacerbation because the
airways are inflamed and mucus the air is having trouble getting in and
out of the lungs
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):
Asthma
Hypertension
Albuterol inhaler 2 puffs
every 4 hours PRN
wheezing
Furosemide 20 mg PO daily
Short-acting
Beta 2-agonist
Loop diuretic
Improve oxygenation/ventilation by
causing smooth muscle relaxation of
bronchioles.
Inhibits the reabsorption of sodium and
chloride from the loop of Henle and
distal renal tubule.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 99.1 F-37.3 C (oral) Provoking/Palliative: Denies pain
P: 110 (regular) Quality:
R: 24 (regular) Region/Radiation:
BP: 188/110 Severity:
O2 sat: 91% RA Timing:
You place John on a cardiac monitor, continuous oximetry
and quickly collect the following assessment data:
© 2019 Keith Rischer/www.KeithRN.com
What vital signs are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion and Maintenance)
Abnormal VS: Clinical Significance:
Respiratory rate of 24
breaths/min
Pulse of 110 beats per
minute
Oxygen saturation of
91% on room air (RA)
Respiratory rate is high, indicating respiratory distress and a severe asthma exacerbation.
This is a clinical red flag! If rate increases or is sustained patient can tire and go into
respiratory arrest
Elevated pulse rate indicates anxiety and increased sympathetic nervous system activity due
to acute
respiratory distress.
All consistent with asthmatic
exacerbation
Low O2 saturation of only 91 percent on RA is indicative of more severe exacerbation and
hypoxia.
What assessment findings are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
APPEARANCE: Appears anxious, body
tense, brows furrowed
RESP: Coarse inspiratory and expiratory
wheezing with prolonged expiratory
phase, labored breathing, diminished
aeration in bases, subcostal retractions
present
SKIN: Cool, moist forehead
Nonverbal body language always communicates something. This body
language communicates that this patient is stressed and anxious.
Clustering this data together the nurse must recognize that this patient is in
severe distress and requires immediate assessment and intervention. The
presence of both inspiratory and expiratory wheezing signifies extreme
narrowing of the bronchioles and is a clinical red flag. Retractions of any
kind that require the use of accessory muscles also is a clinical red flag for
severe respiratory distress.
To think like a nurse students must identify the rationale or why clinical data
is present. Moisture and diaphoresis are always a clinical red flag and is
typically present whenever the sympathetic nervous system is activated. This
confirms the level of distress and the activation of fight or flight!
Put it All Together and Think Like a Nurse!
1. Interpreting relevant clinical data, what is the primary problem? What body system(s) will you assess most
thoroughly based on the primary/priority concern?
What’s the
problem?
What’s causing the problem?
(explain pathophysiology in OWN words)
PRIORITY Body
System to Assess:
Asthma
exacerbation
• Diffuse inflammation and constriction of smaller airways
(bronchioles) also presence of airway edema and increased mucus
production all contribute to decreased diameter of airways>>>
• This leads to air trapping and difficulty with air movement
especially expiration>>>
Respiratory
Current Assessment:
GENERAL: Appears anxious, body tense, brows furrowed
RESP: Coarse inspiratory and expiratory wheezing with prolonged expiratory phase, labored breathing,
diminished aeration in bases, subcostal retractions present
CARDIAC: Skin warm and dry, no edema, heart sounds strong, regular with no abnormal beats/murmurs,
pulses 3+ throughout, brisk cap refill
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen pink, flat, soft/nontender/symmetrical, bowel sounds audible per auscultation in all
four quadrants
GU: Voiding without pain/difficulty, reports urine clear/yellow
INTEGUMENTARY: Cool, moist forehead, skin integrity intact, skin turgor elastic, no tenting present
© 2019 Keith Rischer/www.KeithRN.com
• Which results in an increase in carbon dioxide and decrease in
oxygen level in blood (hypoxemia) and respiratory failure without
intervention
2. Which specific nursing assessments for this body system are most important? Validate successful completion of
each nursing assessment on a manikin (if available) identified with peer or faculty initials.
PRIORITY Nursing Assessments: Rationale: Validate Student
Performance:
• Inspection: Client positioning – tripod,
position of comfort; (face) nasal flaring,
pursed lips, color of face, lips;
(posterior)level of scapula – rise evenly,
use of accessory muscles
anterior/posterior, sternal/intercostal
retractions. Quality and pattern of
respirations.
• Palpation: (posterior) down the back
sequentially checking for
tenderness/pain, warmth, crepitus &
fremitus (best with ball of hand), chest
expansion(symmetry) – thumbs over
spine and fingers spread like butterfly
wings-pneumonia, pneumothorax.
• Percussion: Across and down back for
resonance vs hyperresonance
(pneumothorax), dullness (pneumonia).
• Auscultation: Posterior – down the back
sequentially from C7 (lung apex) to T10;
anterior – above clavicles to sixth rib
(xiphoid); flanks from armpit to 8th rib
• Palpation, percussion and auscultation
follow same pattern and avoids scapula
and spine (posterior) and
mammary tissue (anteriorly) – assess as
close to chest wall as possible. Compare left to
right for aeration =
3. What is the current nursing priority and plan of care?
Nursing PRIORITY: Impaired gas exchange.
Stabilize respiratory status and prevent further worsening of condition
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
Administer oxygen to maintain oxygen
saturation of =/> 93%
Administer short-acting B2 agonist
(albuterol)
Give systemic steroid per IV route and
care provider orders
To promote oxygenation and perfusion of
tissue
Relieve bronchoconstriction and air
trapping
To decrease inflammation in airways
Oxygen saturation will increase
indicating relief of hypoxemia.
Decrease in wheezing,
retractions and use of
accessory muscles, decrease in
respiratory rate.
Decrease in wheezing per
above and other signs of
respiratory distress.
© 2019 Keith Rischer/www.KeithRN.com
Assess vital signs at least every 15 min.
including respiratory rate, heart rate,
and 02 sat
Because the patient is critical the requires
close observation and assessment to
identify the trend or direction that his
condition is going as medical interventions
are implemented
If patient improves his heart
rate will decrease as well as his
respiratory rate. His O2 sat will
then increase.
4. State the rationale and expected outcomes for the medical plan of care.
Medical Management: Rationale: Expected Outcome:
Establish peripheral IV
Methylprednisolone 125 mg
IV
Albuterol 2.5 mg
/ipratropium bromide 0.5 mg
nebulizer.
Reassess after 5 minutes.
May repeat if remains SOB
IV access is needed for IV fluids and IV medications are
also needed in case of worsening of symptoms and
respiratory arrest.
Short burst of steroids decreases inflammation of
airways. An adrenocortical steroid with strong anti-
inflammatory actions as well as immunosuppressive
effects.
Short-acting B2 agonist combined with an
anticholinergic is given during acute exacerbation to
help open up airways and to decrease mucus
production.
Because the nebulizer has an immediate effect,
assessing within five minutes and identifying any trend
of improvement or not will determine the need to repeat
the nebulizer
Peripheral IV started without
difficulty for fluids and
medications.
Improvement of respiratory
status with lessening of asthma
exacerbation signs and
symptoms
Increased air movement, less
wheezing and decreased work
of breathing
Respiratory rate will decrease
and O2 sat will increase after
the first nebulizer
Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Radiology: Chest X-Ray
Results: Clinical Significance:
No infiltrates noted, silhouette of
heart is slightly enlarged
The absence of infiltrates indicates that the cause of his exacerbation is not
infectious related to a problem such as pneumonia.
The enlarged heart is also a clinical red flag that is an abnormal finding that should
not be present in a 35-year-old patient. When a student has a deep understanding of
the pathophysiology of hypertension, if it is not well controlled it can result in
ventricular hypertrophy which will cause a enlarged silhouette of the heart on a
chest x-ray.
Lab Results:
Complete Blood Count (CBC)
WBC HGB PLTs % Neuts Bands
Current: 10.5 14.5 295 78 0
RELEVANT Lab(s): Clinical Significance:
These labs are ALWAYS
RELEVANT, therefore
they must be intentionally
noted by the nurse!
WBC: 10.5
• ALWAYS RELEVANT based on its correlation to the presence of inflammation or infection
© 2019 Keith Rischer/www.KeithRN.com
Hgb: 14.5
Platelets: 295
Neutrophil %: 78%
Bands: 0
• Usually increased if infection present, though it may be decreased in the elderly or peds <3 months
• ALWAYS RELEVANT to determine anemia or acute/chronic blood loss
• Relevant whenever there is a concern for anemia or blood loss or a patient on heparin
• If platelets are low, it will obviously be significant and must be noted
• Any patient on heparin products must also have this noted because of the clinical
possibility of heparin-induced thrombocytopenia (HIT)
• Develops when immune system forms antibodies against heparin that cause small clots and
lower platelet levels
• ALWAYS RELEVANT for same reason as WBCs
• Most common leukocyte
• FIRST RESPONDER to any bacterial infection within several hours or when the
inflammatory response is activated
• Immature neutrophils that are elevated in sepsis as the body attempts to fight infection and
releases these prematurely
If elevated, it’s a clinical RED FLAG in the context of sepsis. If elevated to >8, it is
considered a “shift to the left,” which indicates impending sepsis
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 140 3.2 185 1.3
RELEVANT Lab(s): Clinical Significance:
These labs are ALWAYS
RELEVANT, therefore
they must be intentionally
noted by the nurse!
Sodium: 140
Potassium: 3.2
Glucose: 185
• I consider Na+ the “Crystal-Light” electrolyte. Though this is simplistic, it does help to
understand in principle how basic Na+ is to fluid balance
• When you add one small packet of Crystal Light to your 16-ounce bottle of water, the
concentration is just right. This is where a normal Na+ will be (135-145)
• Where free water goes, sodium will follow to a degree. Therefore if there is a fluid volume
deficit due to dehydration, Na+ will typically be elevated because it’s concentrated (less
water)
• If there is fluid volume excess, Na+ will be diluted and will likely be low. It is the
“foundational” fluid balance electrolyte!
• Why is his potassium low? When students understand pharmacology and the mechanism of
action of a loop diuretic such as furosemide, knowing that this diuretic increases the loss of
potassium and other electrolytes this finding is expected but requires treatment to bring it
within normal range.
• Essential to normal cardiac electrical conduction, as is Mg+
• If too high or low can predispose to rhythm changes that can be life threatening!
• K+ tends to deplete more quickly with loop diuretic usage than Mg+
• Required fuel for metabolism for every cell in the human body, especially the brain
• Relevant with history of diabetes or stress hyperglycemia due to illness
© 2019 Keith Rischer/www.KeithRN.com
Creatinine: 1.3
• Elevated levels post-op can increase risk of infection/sepsis.
• GOLD STANDARD for kidney function and adequacy of renal perfusion
The functioning of the renal system affects every body system; therefore, it is ALWAYS
relevant!
• Why is his creatinine increased? Introduce hypertension and how the increased systolic
blood pressure can damage the glomerular membrane resulting in irreversible kidney
damage and even renal failure if it is not treated or well-controlled.
Evaluation: Thirty minutes later…
1. What data is RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data:
Clinical Significance: TREND: Improve/Worsening/Stable:
P: 96 (reg)
R: 20 (reg)
O2 sat: 95% RA
BP: 146/90
Heart rate is trending DOWN, which is a
clinical improvement!
Respiratory rate is trending DOWN, which is
a clinical improvement!
Oxygenation and ventilation is improving
resulting in improved oxygen saturation
Blood pressure is trending downwards which
Condition is improving because heart
rate is trending down
Condition is improving because
respiratory rate is trending down
Condition is improving because oxygen
saturation is increasing
Condition is improving because his
Current VS: Most Recent: Current PQRST:
T: 99.1 F-37.3 C (oral) T: 99.1 F-37.3 C (oral) Provoking/Palliative:
P: 96 (regular) P: 110 (regular) Quality: Denies
R: 20 (regular) R: 24 (regular) Region/Radiation:
BP: 146/90 BP: 188/110 Severity:
O2 sat: 95% RA O2 sat: 91% RA Timing:
Current Assessment:
GENERAL
APPEARANCE:
Resting comfortably, appears
in no acute distress
RESP: Breath sounds have mild expiratory wheezing with equal aeration bilaterally, able to
speak in
full sentences with no SOB
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4), less anxious
GI: Abdomen pink, flat, soft/nontender/symmetrical, bowel sounds audible per
auscultation in all four quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, skin integrity intact, skin turgor elastic, no tenting present
John has received two albuterol/ipratropium nebulizers and IV
methylprednisolone. You collect the following clinical data to reassess his
status.
© 2019 Keith Rischer/www.KeithRN.com
is most likely due to decreased anxiety and
improved oxygenation
blood pressure is trending down
RELEVANT Assessment
Data:
Clinical Significance: TREND: Improve/Worsening/Stable:
GENERAL APPEARANCE:
Resting comfortably, appears
in no acute distress
RESP: Breath sounds have
mild expiratory wheezing
with equal aeration
bilaterally, able to speak in
full sentences with no SOB
More comfortable than earlier assessment,
no signs of acute distress show that overall
condition has clearly improved
All of the respiratory data clustered
represents improvement in oxygenation.
Some bronchoconstriction is evidenced by
expiratory wheezing, but equal aeration is a
good sign; He is moving air bilaterally.
Condition is improving because he
appears more comfortable
Condition is improving. Though
expiratory wheezing is still present
1. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be
modified after this evaluation assessment? (Management of Care, Physiological Adaptation)
Evaluation of Current Status: Modifications to Current Plan of Care:
Yes, condition has clearly improved with
nebulizer treatments and higher flow O2 via
nasal cannula and excellent nursing care!
Top priority remains to closely assess respiratory status. Will want to
closely monitor respiratory status with O2 saturation and overall
clinical picture to continue to establish clinical TRENDS.
2. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and
weaknesses this case study identified. What is your plan to make any weakness a future
strength?
What Did You Learn? What did you do well with this case study?
What could have been done better? What is your plan to make any weakness a future
strength?
© 2019 Keith Rischer/www.KeithRN.com
Author
Keith Rischer, RN, MA, CEN, CCRN
Reviewers
Sarah R. Pierce, DNP, MSN, AGACNP-BC, CCRN, PLNC, PLCP, Assistant Professor, Department of
Nursing, Freed-Hardeman University, Henderson, Tennessee
References
Berman, A., Snyder, S. & Frandsen, G. (2016). Fundamentals of nursing. (9th ed.). Upper Saddle River, NJ: Prentice
Hall.
Hogan, M. (2018). Comprehensive Review for NCLEX-RN. New York, NY: Pearson.
Ignatavicius, D.D. & Workman, M.L. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed.).
St. Louis, MO: Elsevier.
Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2014) Davis’s drug guide for nurses. (14th ed.). Philadelphia, PA: F.A.
Davis Company.
Van Leeuwen, A. & Bladh, M.L. (2015). Davis’s comprehensive handbook of laboratory and diagnostic tests with
nursing implications. (6th ed.). Philadelphia, PA: F.A. Davis Company.
